Despite a decade of concerted prevention and research efforts, young women in South Africa remain at the epicenter of the global HIV epidemic. Young women in South African experience high rates of pregnancy and are twice as likely to be HIV infected as their same age male peers. At Prince Mshiyeni Memorial Hospital, a provincial government hospital and the proposed recruitment site for the current study, half of all antenatal clinic attendees are infected. Prevalence rises from 7% among 16 year olds to 54% among 22 year olds, suggesting that late adolescence represents a critical period during which large numbers of young women are becoming infected. Young South Africans becoming infected with HIV today grew up in an era where their parents and families were powerfully affected by HIV related illness, economic hardship, and death, but may also benefit from increased government and community attention to HIV. Systematic investigation into how growing up as the second generation of HIV-affected youth and its impact on current explosive rates of infection is lacking. Preliminary data from pregnant adolescents receiving care at PMMH suggest new patterns of behavior that likely contribute to high infection rates, but thus far remain undocumented in the scientific literature. Examples include participation in multiple, unprotected sexual encounters at 24-hour parties (known as nkwari) with concomitant alcohol and drug use and the desire to achieve pregnancy to preserve social relationships. A broader, ecological understanding of the evolving contextual factors that drive HIV risk behavior in this second generation is crucial in order to develop more effective and relevant behavioral interventions, and for successful implementation and roll-out of biological prevention measures. As estimates for a viable vaccine roll-out could be at least a decade away, effective interventions will need to respond to a dynamic and ever-changing epidemic for years to come. Project overview. The proposed study will use qualitative methods identify novel factors influencing HIV transmission risk in the second generation of young women in a South African HIV hyper-endemic setting. We will particularly explore (a) fertility desire, (b) increasing access to treatment and future biological prevention strategies; and (c) ART optimism, HIV prevention fatigue and HIV fatalism (d) and how these may be influenced by early childhood trauma and loss in being born into and raised in a community devastated by HIV. PUBLIC HEALTH RELEVANCE: Rates of HIV infection among young women in South Africa are among the highest in the world. Adolescent women in South Africa represent part of the second generation of HIV affected youth, a cohort that remains understudied. Adolescent women coming of age today likely have different experiences related to HIV than the generation before; we plan to explore how the experiences of these women may impact current HIV risk behavior with the ultimate goal of learning how to best intervene in order to reduce rates of HIV in the future.